Barriers to web-based symptom management systems (web-SyMS)

6545

Background: Web-SyMS can reduce the burdens of cancer and its treatment. While patients frequently express willingness to use these systems, only a subset actively engages with them. Some patients may lack the tools and confidence needed to benefit from web-SyMS. We sought to characterize these barriers among community-based cancer patients receiving care across six diverse healthcare systems. Methods: We surveyed patients receiving chemotherapy at three healthcare systems (Baptist, TN; Maine Medical, ME; Dana-Farber, MA) and patients recovering from cancer-directed surgery at three healthcare systems (West Virginia University, WV; Dartmouth-Hitchcock, NH; Lifespan, RI). Surveys were conducted as part of a pre-implementation analysis of eSyM – an EHR-embedded web-SyMS that collects, tracks, and manages patient reported outcomes during cancer therapy. Results: Among 563 respondents, access to tech devices (i.e., tablet, computer, or smartphone) was high: 78% reported access to ≥2 devices and only 5% reported access to no devices. However, confidence using tech devices to accomplish online tasks varied: 45% very confident, 38% somewhat confident, 11% little-no confidence. Compared to medical oncology patients, surgery patients were more likely to report being very confident (57% vs. 31%). There were significant differences based on patients’ self-reported tech confidence (Chi-square P<.05 for all values in the table). Conclusions: Low self-reported tech confidence may identify patients who are at high risk for experiencing the burdens of cancer but may be less likely to benefit from web-SyMS. Addressing this barrier is critical to improving outcomes and addressing disparities. Clinical trial information: NCT03850912. [Table: see text]

Physician concern about delaying lung cancer treatment while awaiting biomarker testing: Results of a survey of U.S. oncologists

9067

Background: With rapid advancements in biomarker testing informing lung cancer treatment decisions, clinicians are challenged to maintain knowledge of who, what and when to test and how to treat based on test results. An ASCO taskforce including representatives from the American Cancer Society National Lung Cancer Roundtable and patient advocates conducted a study to assess biomarker testing and treatment practices for patients with advanced non-small cell lung cancer (aNSCLC) among U.S. oncologists. Methods: A survey was sent to 2374 ASCO members – lung cancer specialists and general oncologists. Eligibility required treating ≥1 lung cancer patient/month. Proportions were estimated across groups and compared using chi-square tests. Results: 170 responses were analyzed. 59% of respondents work at an academic center (i.e., have a fellowship program), while 41% work at a community (non-academic hospital/health system/private practice). Nearly all (98%) believe biomarker results should be received within 1 or 2 weeks of ordering, yet 37% wait an average of 3 or 4 weeks for results. Of respondents who usually wait 3 or 4 weeks, 37% initiate a non-targeted systemic treatment while waiting. Respondents from community practices were more likely to initiate non-targeted systemic treatment if results were not available after 2 weeks (59% compared to 40% of academic respondents; p = 0.013). ). When asked about reasons for not testing, respondents <5 years since training were more likely to report that delaying treatment while waiting for results was always/often a concern compared to those >6 years from training (41% vs 19%). Respondents reported high testing rates in both non-squamous and squamous aNSCLC. Roughly equal representation of generalists/specialists and academic/community respondents helps mitigate potential concerns about external validity. Conclusions: Respondents indicated that treatment decisions are impacted by delays in biomarker test results. Clinicians should be informed about when it is safe and appropriate to defer treatment while biomarker testing is pending. Respondents suggest that diagnostic biomarker testing companies should strive to expedite results.[Table: see text]

A phase II study of rucaparib in patients with high genomic LOH and/or BRCA 1/2 mutated stage IV non-small cell lung cancer (Lung-MAP Sub-Study, S1900A)

9024

Background: While prior studies have shown robust efficacy leading to FDA approval of PARP inhibitors (PARPi) in BRCA-associated cancers, data in NSCLC are much less clear. S1900A, a LUNG-MAP substudy, evaluated the PARPi rucaparib in advanced stage NSCLC harboring BRCA1/2 mutations or genomic loss of heterozygosity (LOH) as a phenotypic marker of homologous recombination deficiency (HRD). Methods: Eligible patients (pts) were required to have a deleterious mutation in BRCA1/BRCA2 and/or high (≥21%) genomic LOH. Key eligibility criteria: advanced NSCLC patients (pts) with progression on or after platinum based chemotherapy and/or PD-(L)1 antibody and progressed on most recent line of systemic therapy, a Zubrod performance status of 0-1, adequate organ function, no ≥ grade 3 hypercholesterolemia, no previous PARPi exposure and no systemic therapy within 21 days of registration. Pts stratified by histology into two cohorts (squamous [sq] and non-squamous/mixed histology [nsq]). With 40 eligible pts per cohort, the design had 91% power to rule out an ORR of 15% if the true ORR was at least 35% at the 1-sided 5% level. A planned interim analysis on the first 20 pts evaluable for response per cohort required ≥ 3 responses to proceed to full enrollment. Results: 64 pts enrolled (27 sq cohort; 37 nsq cohort) of whom 59 are eligible. Median age 65.7 yrs; M/F 33/26 (56/44%); 98% of the pts received at least 1 prior line of treatment for stage IV disease. Biomarker selection included 36 pts (61%) LOH only, 4 pts (7%) BRCA1 only, 11 pts (19%) BRCA2 only, 4 pts (7%) BRCA1 + LOH high and 4 pts (7%) BRCA2 + LOH high. Both cohorts were closed for futility with insufficient responses in the interim analysis populations. In the full study, 4 responses (3 nsq/1 sq) were reported. ORR was 7% (95% CI: 0-13) (9% nsq/4% sq) and DCR was 62% (95% CI: 50-75) (62% nsq/64% sq); 3 of the 4 responders harbored BRCA1/2 mutations and 1 of 4 high LOH; ORR in BRCA1/2+ pts 3/23 (13%). Median PFS was 3.2 months (95% CI: 1.6-4.6) in nsq cohort and 2.9 months (95% CI 1.6-6.2) in sq cohort. Median OS was 7.8 months in nsq cohort and 7.9 months in sq cohort. The most frequent grade ≥3 adverse events were anemia (22%), lymphopenia (8%), fatigue (8%) and transaminitis (5%). Conclusions: S1900A failed to show the requisite level of efficacy for rucaparib in advanced NSCLC pts with high genomic LOH and/or a BRCA1/2 mutation. There were no new safety signals and hematologic toxicities were the most frequent adverse events. Genomic LOH as a phenotypic marker of HRD does not predict sufficient activity of rucaparib in NSCLC. These results stand in contrast to the high level of efficacy of PARPi in patients with BRCA-associated or high LOH cancers of other tumor types. Underlying biologic differences in the genomic characteristics of these cancers vs. NSCLC may be responsible. Studies examining this premise are ongoing. (NCT03845296). Clinical trial information: NCT03845296.

Blood-based biomarker analysis in high PD-L1 expressing NSCLC treated with PD-1/PD-L1 based therapy with or without the addition of platinum-based chemotherapy

TPS9126

Background: Immunotherapy directed against the programmed death-1 / ligand-1 (PD-1/L1) axis has revolutionized the treatment of advanced non-small cell lung cancer (aNSCLC). Tumor PD-L1 is currently the only biomarker validated for predicting patient response to front line PD-1/L1 directed immunotherapy, yet 20% of patients with ≥50% PD-L1 expression die within six months of starting therapy (Reck et al. 2016). Blood-based agents such as autoantibodies and circulating inflammatory biomarkers have stratified patient outcomes on anti-PD-1/L1 immunotherapy in preliminary studies (Tarhoni, Kollipara et al. 2019; Tarhoni, Fidler et al. 2019). Moreover, a serum-based proteomic test that uses mass spectrometry and machine learning to provide three classifications (Good, Intermediate and Poor) has stratified non-treatment naïve aNSLCC patients treated with nivolumab based on their outcomes (Mueller et al. 2020) and identified a subset of patients who progressed rapidly. This study will evaluate these blood-based biomarkers as predictors of response and early progression in patients with >50% PD-L1 positive aNSCLC treated with immunotherapy regimens. Methods: This is a prospective, observational, multicenter study (NCT04676386) designed to assess biomarkers (serum and plasma) as predictive of early progression in 390 patients with aNSCLC treated with anti-PD 1/PD-L1 immunotherapy with or without platinum-based chemotherapy. Key eligibility criteria are treatment naïve aNSCLC with tumor biopsy PD-L1 tumor proportion score > 50%, Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2, and ability to consent to participate. Prior to enrollment, tumor specimens will be tested for PD-L1 expression according to participating centers’ standard operating procedures. For each treatment cohort of 195 patients, enrollment will proceed in sub-cohorts to ensure a population with 20% patients with ECOG PS2 and a total of 40 patients with squamous cell carcinoma per treatment arm. Patients will be followed for a maximum of 3 years. Blood draw for biomarker assessment will be performed prior to treatment initiation, start of 3rd cycle and investigator assessed progression. Biomarker analysis will be performed retrospectively. As a secondary objective, this study will evaluate proteomic test performance in predicting early overall survival (OS) and rapid progression, and in stratifying patient survival and response. Exploratory analyses will correlate baseline and serial circulating protein analytes and autoantibodies with the proteomic test, response measures (RECIST 1.1) and toxicities. Enrollment opened in February 2021. Clinical trial information: NCT04676386.

Modernizing Clinical Trial Eligibility Criteria: Recommendations of the ASCO-Friends of Cancer Research Prior Therapies Work Group

PURPOSE

Restrictive eligibility criteria induce differences between clinical trial and "real-world" treatment populations. Restrictions based on prior therapies are common; minimizing them when appropriate may increase patient participation in clinical trials.

EXPERIMENTAL DESIGN

A multi-stakeholder working group developed a conceptual framework to guide evaluation of prevailing practices with respect to using prior treatment as selection criteria for clinical trials. The working group made recommendations to minimize restrictions based on prior therapies within the boundaries of scientific validity, patient centeredness, distributive justice, and beneficence.

RECOMMENDATIONS

(i) Patients are eligible for clinical trials regardless of the number or type of prior therapies and without requiring a specific therapy prior to enrollment unless a scientific or clinically based rationale is provided as justification. (ii) Prior therapy (either limits on number and type of prior therapies or requirements for specific therapies before enrollment) could be used to determine eligibility in the following cases: a) the agents being studied target a specific mechanism or pathway that could potentially interact with a prior therapy; b) the study design requires that all patients begin protocol-specified treatment at the same point in the disease trajectory; and c) in randomized clinical studies, if the therapy in the control arm is not appropriate for the patient due to previous therapies received. (iii) Trial designers should consider conducting evaluation separately from the primary endpoint analysis for participants who have received prior therapies.

CONCLUSIONS

Clinical trial sponsors and regulators should thoughtfully reexamine the use of prior therapy exposure as selection criteria to maximize clinical trial participation.See related commentary by Giantonio, p. 2369.

The Anatomy and Physiology of Teaming in Cancer Care Delivery: A Conceptual Framework

Care coordination challenges for patients with cancer continue to grow as expanding treatment options, multimodality treatment regimens, and an aging population with comorbid conditions intensify demands for multidisciplinary cancer care. Effective teamwork is a critical yet understudied cornerstone of coordinated cancer care delivery. For example, comprehensive lung cancer care involves a clinical "team of teams"-or clinical multiteam system (MTS)-coordinating decisions and care across specialties, providers, and settings. The teamwork processes within and between these teams lay the foundation for coordinated care. Although the need to work as a team and coordinate across disciplinary, organizational, and geographic boundaries increases, evidence identifying and improving the teamwork processes underlying care coordination and delivery among the multiple teams involved remains sparse. This commentary synthesizes MTS structure characteristics and teamwork processes into a conceptual framework called the cancer MTS framework to advance future cancer care delivery research addressing evidence gaps in care coordination. Included constructs were identified from published frameworks, discussions at the 2016 National Cancer Institute-American Society of Clinical Oncology Teams in Cancer Care Workshop, and expert input. A case example in lung cancer provided practical grounding for framework refinement. The cancer MTS framework identifies team structure variables and teamwork processes affecting cancer care delivery, related outcomes, and contextual variables hypothesized to influence coordination within and between the multiple clinical teams involved. We discuss how the framework might be used to identify care delivery research gaps, develop hypothesis-driven research examining clinical team functioning, and support conceptual coherence across studies examining teamwork and care coordination and their impact on cancer outcomes.

Impact of a Lymph Node Specimen Collection Kit on the Distribution and Survival Implications of the Proposed Revised Lung Cancer Residual Disease Classification: A Propensity-Matched Analysis

IMPORTANCE

The International Association for the Study of Lung Cancer (IASLC) has proposed a revision of the residual disease (R-factor) classification, to R0, 'R-uncertain', R1 and R2. We previously demonstrated longer survival after surgical resection with a lymph node specimen collection kit, and now evaluate R-factor redistribution as the mechanism of its survival benefit.

OBJECTIVE

We retrospectively evaluated surgical resections for lung cancer in the population-based observational 'Mid-South Quality of Surgical Resection' cohort from 2009-2019, including a full-cohort and propensity-score matched analysis.

RESULTS

Of 3,505 resections, 34% were R0, 60% R-uncertain, and 6% R1 or R2. The R0 percentage increased from 9% in 2009 to 56% in 2019 (p < 0.0001). Kit cases were 66% R0 and 29% R-uncertain, compared to 14% R0 and 79% R-uncertain in non-kit cases (p < 0.0001). Compared with non-kit resections, kit resections had 12.3 times the adjusted odds of R0 versus R-uncertainty.Of 2,100 R-uncertain resections, kit cases had lower percentages of non-examination of lymph nodes, 1% vs. 14% (p < 0.0001) and non-examination of mediastinal lymph nodes, 8% vs. 35% (p < 0.0001). With the kit, more R-uncertain cases had examination of stations 7 (43% vs. 22%, p < 0.0001) and 10 (67% vs. 45%, p < 0.0001).The adjusted hazard ratio (aHR) for kit cases versus non-kit cases was 0.75 (confidence interval [CI]: 0.66-0.85, p < 0.0001). In 2,100 subjects with R-uncertain resections, kit cases had an aHR of 0.79 versus non-kit cases ([CI: 0.64-0.99], p=0.0384); however, in the 1,199 R0 resections the survival difference was not significant (aHR: 0.85[0.68-1.07], p = 0.17).

CONCLUSIONS AND RELEVANCE

A lymph node kit increased overall survival by increasing R0, reducing the probability of R-uncertain resections, and diminishing extreme R-uncertainty.

Institutional-Level Differences in Quality and Outcomes of Lung Cancer Resections in the United States

BACKGROUND

Institutional-level disparities in non-small cell lung cancer (NSCLC) survival may be driven by reversible differences in care-delivery processes. We quantified the impact of differences in readily identifiable quality metrics on long-term survival disparities in resected NSCLC.

RESEARCH QUESTION

How do reversible differences in oncologic quality of care contribute to institutional-level disparities in early-stage NSCLC survival?

STUDY DESIGN AND METHODS

We retrospectively analyzed patients in the National Cancer Data Base who underwent NSCLC resection from 2004 through 2015 within institutions categorized as Community, Comprehensive Community, Integrated Network, Academic, and National Cancer Institute (NCI)-Designated Cancer Programs. We estimated percentages and adjusted ORs for six potentially avoidable poor-quality markers: incomplete resection, nonexamination of lymph nodes, nonanatomic resection, non-evidence-based use of adjuvant chemotherapy, non-evidence-based use of adjuvant radiation therapy, and 60-day postoperative mortality. By sequentially eliminating patients with poor-quality markers and calculating adjusted hazard ratios, we quantified their overall survival impact.

RESULTS

Of 169,775 patients, 7%, 46%, 10%, 24%, and 12% underwent surgery at Community, Comprehensive Community, Integrated Network, Academic, and NCI-Designated Cancer Programs, with 5-year overall survival rates of 52%, 56%, 58%, 60% and 66%, respectively. After the sequential elimination process, using NCI-Designated Cancer Centers as a reference, the adjusted hazard ratio for 5-year overall survival changed from 1.47 (95% CI, 1.41-1.53), 1.29 (95% CI, 1.25-1.33), 1.18 (95% CI, 1.14-1.23), and 1.20 (95% CI, 1.16-1.24) for Community, Comprehensive Community, Integrated Networks, and Academic Cancer Programs to 1.35 (95% CI, 1.28-1.42), 1.22 (95% CI, 1.17-1.26), 1.16 (95% CI, 1.11-1.22), and 1.17 (95% CI, 1.12-1.21), respectively (P < .001 for all comparisons with NCI-designated programs). Differences in quality of surgical resection and postoperative care accounted for 11% to 26% of the interinstitutional survival disparities.

INTERPRETATION

Targeting six readily identified poor-quality markers narrowed, but did not eliminate, institutional survival disparities. The greatest impact was in community programs. Residual factors driving persistent institution-level long-term NSCLC survival disparities must be characterized to eliminate them.

Persistent Disparity: Socioeconomic Deprivation and Cancer Outcomes in Patients Treated in Clinical Trials

Patients with cancer living in socioeconomically disadvantaged areas have worse cancer outcomes. The association between socioeconomic deprivation and outcomes among patients with cancer participating in clinical trials has not been systematically examined.

"When Offered to Participate": A Systematic Review and Meta-Analysis of Patient Agreement to Participate in Cancer Clinical Trials

BACKGROUND

Patient participation in clinical trials is vital for knowledge advancement and outcomes improvement. Few adult cancer patients participate in trials. Although patient.

decision-making about trial participation has been frequently examined, the participation rate for patients actually offered a trial is unknown.

METHODS

A systematic review and meta-analysis using 3 major search engines was undertaken. We identified studies from January 1, 2000, to January 1, 2020, that examined clinical trial participation in the United States. Studies must have specified the numbers of patients offered a trial and the number enrolled. A random effects model of proportions was used. All statistical tests were 2-sided.

RESULTS

We identified 35 studies (30 about treatment trials and 5 about cancer control trials) among which 9759 patients were offered trial participation. Overall, 55.0% (95% confidence interval [CI] = 49.4% to 60.5%) of patients agreed to enroll. Participation rates did not differ between treatment (55.0%, 95% CI = 48.9% to 60.9%) and cancer control trials (55.3%, 95% CI = 38.9% to 71.1%; P = .98). Black patients participated at similar rates (58.4%, 95% CI = 46.8% to 69.7%) compared with White patients (55.1%, 95% CI = 44.3% to 65.6%; P = .88). The main reasons for nonparticipation were treatment choice or lack of interest.

CONCLUSIONS

More than half of all cancer patients offered a clinical trial do participate. These findings upend several conventional beliefs about cancer clinical trial participation, including that Black patients are less likely to agree to participate and that patient decision-making is the primary barrier to participation. Policies and interventions to improve clinical trial participation should focus more on modifiable systemic structural and clinical barriers, such as improving access to available trials and broadening eligibility criteria.

Immune-Based Cancer Treatment: Addressing Disparities in Access and Outcomes

Avoidable differences in the care and outcomes of patients with cancer (i.e., cancer care disparities) emerge or worsen with discoveries of new, more effective approaches to cancer diagnosis and treatment. The rapidly expanding use of immunotherapy for many different cancers across the spectrum from late to early stages has, predictably, been followed by emerging evidence of disparities in access to these highly effective but expensive treatments. The danger that these new treatments will further widen preexisting cancer care and outcome disparities requires urgent corrective intervention. Using a multilevel etiologic framework that categorizes the targets of intervention at the individual, provider, health care system, and social policy levels, we discuss options for a comprehensive approach to prevent and, where necessary, eliminate disparities in access to the clinical trials that are defining the optimal use of immunotherapy for cancer, as well as its safe use in routine care among appropriately diverse populations. We make the case that, contrary to the traditional focus on the individual level in descriptive reports of health care disparities, there is sequentially greater leverage at the provider, health care system, and social policy levels to overcome the challenge of cancer care and outcomes disparities, including access to immunotherapy. We also cite examples of effective government-sponsored and policy-level interventions, such as the National Cancer Institute Minority-Underserved Community Oncology Research Program and the Affordable Care Act, that have expanded clinical trial access and access to high-quality cancer care in general.

Outcomes After Use of a Lymph Node Collection Kit for Lung Cancer Surgery: A Pragmatic, Population-Based, Multi-Institutional, Staggered Implementation Study

INTRODUCTION

Suboptimal pathologic nodal staging prevails after curative-intent resection of lung cancer. We evaluated the impact of a lymph node specimen collection kit on lung cancer surgery outcomes in a prospective, population-based, staggered implementation study.

METHODS

From January 1, 2014, to August 28, 2018, we implemented the kit in three homogeneous institutional cohorts involving 11 eligible hospitals from four contiguous hospital referral regions. Our primary outcome was pathologic nodal staging quality, defined by the following evidence-based measures: the number of lymph nodes or stations examined, proportions with poor-quality markers such as nonexamination of lymph nodes, and aggregate quality benchmarks including the National Comprehensive Cancer Network criteria. Additional outcomes included perioperative complications, health care utilization, and overall survival.

RESULTS

Of 1492 participants, 56% had resection with the kit and 44% without. Pathologic nodal staging quality was significantly higher in the kit cases: 0.2% of kit cases versus 9.8% of nonkit cases had no lymph nodes examined; 3.2% versus 25.3% had no mediastinal lymph nodes; 75% versus 26% attained the National Comprehensive Cancer Network criteria (p < 0.0001 for all comparisons). Kit cases revealed no difference in perioperative complications or health care utilization except for significantly shorter duration of surgery, lower proportions with atelectasis, and slightly higher use of blood transfusion. Resection with the kit was associated with a lower hazard of death (crude, 0.78 [95% confidence interval: 0.61-0.99]; adjusted 0.85 [0.71-1.02]).

CONCLUSIONS

Lung cancer surgery with a lymph node collection kit significantly improved pathologic nodal staging quality, with a trend toward survival improvement, without excessive perioperative morbidity or mortality.

Comparative Effectiveness of a Lymph Node Collection Kit Versus Heightened Awareness on Lung Cancer Surgery Quality and Outcomes

INTRODUCTION

The adverse prognostic impact of poor pathologic nodal staging has stimulated efforts to heighten awareness of the problem through guidelines, without guidance on processes to overcome it. We compared heightened awareness (HA) of nodal staging quality versus a lymph node collection kit.

METHODS

We categorized curative-intent lung cancer resections from 2009 to 2020 in a population-based, nonrandomized stepped-wedge implementation study of both interventions, into preintervention baseline, HA, and kit subcohorts. We used differences in proportion and hazard ratios across the subcohorts to estimate the effect of the interventions on poor quality (nonexamination of nodes [pNX] or nonexamination of mediastinal lymph nodes) and attainment of quality recommendations of the National Comprehensive Cancer Network, the Commission on Cancer, and the proposed complete resection definition of the International Association for the Study of Lung Cancer across the three cohorts.

RESULTS

Of 3734 resections, 39% were preintervention, 40% kit, and 21% HA cases. Cohort proportions were the following: pNX, 11% (baseline) versus 0% (kit) versus 9% (HA); nonexamination of mediastinal lymph nodes, 27% versus 1% versus 22%; Commission on Cancer benchmark attainment, 14% versus 77% versus 30%; International Association for the Study of Lung Cancer-defined complete resection, 11% versus 58% versus 24%; National Comprehensive Cancer Network attainment, 23% versus 79% versus 35% (p < 0.001 for all, except pNX rate baseline versus HA). Survival rate was significantly higher for both interventions compared with baseline (p < 0.0001).

CONCLUSIONS

Resections with HA or the kit significantly improved surgical quality and outcomes, but the kit was more effective. We propose to conduct a prospective, institutional cluster-randomized clinical trial comparing both interventions.

Stakeholder feedback at four ePRO-naïve healthcare institutions about the need, effectiveness, and barriers to usage of a fully EHR-integrated ePRO tool

165

Background: Collecting patient-reported outcomes (PROs) is a proven method to enhance doctor-patient communication and care. With the influx of technology and usage of telehealth services, electronic PROs (ePROS) have become the mainstay for ascertaining how a patient is doing at home. Collection of ePROs is particularly valuable for providers caring for rural and vulnerable populations with limited access to high quality care. A fully EHR-integrated ePRO collection system could help bridge the gap. Methods: To inform the design, function, and deployment of a new EHR-integrated ePRO symptom management system, focus groups with stakeholders were conducted at four institutions caring for largely rural-based populations (Baptist Cancer Center, West Virginia University Cancer Institute, Dartmouth-Hitchcock Medical Center, Maine Medical Center). Sessions were conducted 2 to 3 months prior to the launch of a new ePRO platform and included oncologists, surgeons, practice nurses, tech analysts, operations staff, and institutional leadership. Each group included a 30-minute overview of the new tool followed by a 30-minute discussion with qualitative open-ended questions and clicker-enabled multiple-choice questions. Developed questions utilized the CFIR and RE-AIM implementation frameworks. Results: In total, 134 stakeholders participated from the four institutions. RNs made up nearly half of respondents (47%). 97% of participants felt a new ePRO system would complement existing healthcare initiatives and 64% felt it would be extremely effective/very effective in improving symptom management. Each group was asked to rate the barriers to patient usage of an ePRO system in the home-care setting. Computer literacy (51%) and access to an internet-enabled device (48%) ranked as the highest barriers. Other barriers perceived to be of less significance included privacy, distrust, and limited English-language proficiency. Consequently, two-thirds of respondents felt patients would only be somewhat likely/not so likely to use an ePRO system; one-third felt patients would be likely/extremely likely to utilize the system. Conclusions: From the perspective of stakeholders at four engaged institutions, an integrated ePRO tool is considered a widely acceptable symptom management solution, but uncertainty remains around patient acceptance and uptake. Future research will include post-implementation discussions with stakeholders and evaluation of patient utilization and clinical outcomes.

Development of self-management tip sheets for medical oncology and surgical patients electronically reporting symptoms in the home-care recovery setting

299

Background: Patients receiving cancer treatments, including chemotherapy and surgery, often face immense morbidities. Poor symptom control frequently leads to decreased quality of life and an increased need for acute care services. For patients undergoing chemo, adverse side effects can deter them from receiving life-saving therapies. Similarly, poorly managed postoperative symptoms can delay recovery and timely receipt of adjuvant therapies. Empowering patients to proactively monitor, electronically report, and effectively treat symptoms in the home-care setting is critical to improving clinical outcomes. Methods: Through the NCI’s Moonshot-funded IMPACT consortium, 6 health systems developed a library of 70 open source symptom management tip sheets for medical oncology and surgical patients. The study team went through an iterative process with medical oncologists, surgeons, practice nurses, health educators, and patient advocates. Careful attention was paid to minimize the usage of regional dialects or idioms to ensure scalability and acceptability. The tip sheets achieved passing scores on two validated healthy literacy and readability tools. Results: Tip sheets were accessible to patients participating in the novel eSyM (electronic symptom management) program, a fully EHR-integrated ePRO model.eSyM and the incorporated tips were deployed at four health systems between fall 2019 and spring 2020 (Baptist Cancer Center, West Virginia University, Dartmouth-Hitchcock Medical Center, and Maine Medical Center). Patients enrolled in eSyM had access to the tip sheet library through their patient portal and could view them at any time. In addition, after completing an ePRO questionnaire, patients were given dedicated links to the tips for symptoms they reported. Each developed tip sheet included 4 sections: 1) things you can do on your own, 2) with over-the-counter medications, 3) with the help of your care team, 4) when to call your care team for help. This simplified structure allowed patients to determine how to manage symptoms on their own and when to seek out assistance. Conclusions: Presenting self-management tip sheets in response to patient-reported symptoms through a fully integrated patient portal platform is a novel approach to symptom management. Future efforts will include deploying the library and platform at two additional health institutions and evaluating the adoption, acceptability, and utilization of the tip sheets and their impact on clinical care outcomes.

Design of eSyM: An ePRO-based symptom management tool fully integrated in the electronic health record (Epic) to foster patient/clinician engagement, sustainability, and clinical impact

164

Background: Chemotherapy and surgery can cause distressing symptoms, which can be a burden for health systems to address. Programs that directly engage patients, including electronic tracking of patient-reported outcomes (ePROs), can improve symptom control and decrease the need for acute care. Previous ePRO programs have relied on third party vendors with limited EHR integration, constraining their clinical utility and scalability. An integrated solution could offer distinct advantages. Methods: As part of NCI’s Moonshot-funded IMPACT consortium, 6 health systems and Epic built an electronic symptom management program (eSyM) based on the PRO-CTCAE questionnaire that is fully integrated into the EHR. The agile, user-centered design process engaged patients, clinicians, and institutions. The core functional components include: 1) symptom surveys in the postoperative period or between chemotherapy visits, 2) self-management tip sheets, 3) clinician alerts, and 4) dashboards for population management. Critical points of integration with supporting EHR functions and workflow impacts were identified; and major challenges of integration and implementation were described. Results: eSyM, which was implemented at two health systems (Baptist Memorial in Tennessee and Mississippi and West Virginia University Health) in the fall of 2019, required multiple supporting EHR functions: 1) access a secure, HIPPA-compliant patient portal/messaging system (MyChart); 2) record diagnosis, procedure and chemotherapy treatment plan data; 3) identify target populations and track metrics/events; 4) define and execute autonomous logic-based workflow rules; 5) generate reports for clinicians/patients; and 6) documentation. Major challenges included: 1) working within pre-existing EHR system standards and capabilities, which limited the ability to customize interfaces and workflows specifically for the eSyM use case; and 2) adapting to different EHR configurations and polices across multiple health systems. Conclusions: The eSyM build leveraged many existing EHR capabilities and overcame regulatory hurdles; but it required design and workflow compromise. Integration of ePRO-based symptom management programs into the EHR could help overcome barriers, consolidate clinical workflows, and foster scalability/sustainability. Ongoing efforts include launching eSyM at four more sites and evaluating its adoption, usability, and impact on clinical outcomes.

An Optimal Care Coordination Model (OCCM) for Medicaid patients with lung cancer: Results from the beta model testing phase of a multisite initiative in the United States

105

Background: Medicaid patients with lung cancer have poorer outcomes than non-Medicaid patients, partly because of suboptimal care quality. The Association of Community Cancer Centers (ACCC) launched a project to develop, test, and refine an OCCM. Methods: The OCCM comprised 13 areas, spanning care access to supportive care/survivorship. Using the OCCM, 7 cancer programs in 6 US states conducted self-assessments of care delivery systems and implemented quality improvement projects. Sites worked with ACCC to conduct data benchmarked projects. Data collection and analysis were centralized. Statistical analyses used Kruskal−Wallis and chi-squared tests. Results: There were 926 patients (257 Medicaid/dual eligible; 669 non-Medicaid) across 7 sites. Medicaid/dual eligible patients were 52% male, 69% Caucasian, 48% active smokers, and 45% clinical stage III/IV. Prospective multidisciplinary case planning (PMCP), patient care access, and tobacco cessation were commonly selected for projects. PMCP evaluation used fortnightly tumor board (FTB), virtual tumor board (VTB), and multidisciplinary team huddle (MTH). Presentation of eligible patients was higher for VTB and MTH (FTB: 23%, VTB: 100%, MTH: 100%, p < 0.0001). While FTB and MTH discussed all cases prospectively, VTB achieved 80%. Median days (d) from diagnosis to presentation were 18 (FTB), 14 (VTB), and 9 (MTH, p = 0.14). Patient care access was evaluated with timeliness metrics at 2 sites. Site 1: Medicaid patients had a median of 13 d from lesion discovery to diagnosis and 21 d from diagnosis to treatment (not different from non-Medicaid; p = 0.96 and 0.38). 94% met the goal of treatment initiation within 45 d. Site 2: Medicaid patients had a median of 16 d from discovery to diagnosis and 27 d from diagnosis to treatment (not different from non-Medicaid; p = 0.68 and 0.83). Similar benchmarks were collected and compared for other assessment areas. Sites identified enhanced collaboration and improved programming (e.g., patient navigation) as successes. Challenges at project start included inadequate staffing and lack of centralized data collection and benchmarking. Importance of lung cancer–dedicated navigation, PMCP, and Medicaid patient needs were key transferable lessons. Conclusions: The OCCM is useful for cancer programs’ self-assessment of care delivery to Medicaid patients across 13 high-impact areas. Dissemination can advance multidisciplinary coordinated care delivery, but sites may need additional resources to evaluate outcomes.

Outcomes from a multidisciplinary thoracic oncology conference (MTOC) versus serial care (SC) in a community healthcare system

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Background: Lung cancer care delivery is complex, with disparate quality and outcomes. Prospective multidisciplinary case planning is a recommended but poorly validated solution. We conducted a prospective comparative effectiveness trial to evaluate the impact of multidisciplinary care on care processes and long-term survival in a large community-based healthcare system. Methods: We previously reported primary objective results comparing patients in the multidisciplinary clinic (MDC) with those not cared for in the MDC i.e. usual, SC. However, a subset of the SC subjects (and all MDC subjects) were discussed at a weekly MTOC. In this secondary analysis, we compare all subjects who were prospectively discussed at MTOC (with or without MDC) with ‘true’ SC (TSC). Subjects were frequency matched by age range, race, insurance, performance status, and initial clinical stage. We compared the thoroughness of staging, use of guideline-concordant treatment, and survival. Models were stratified by frequency matched variables and adjusted for age, sex, and histology as covariates. Statistical methods included chi-square, logistic regression with adjusted Odds Ratios (aOR), and Proportional Hazards models with adjusted Hazard Ratios (aHR); both with 95% confidence intervals. Results: Of 526 subjects enrolled, 246 (47%) were discussed at MTOC. MTOC patients were older (median age 68 v 66, p = 0.03), less intense smokers (p = 0.03), and more commercially insured (p = 0.02). Fewer MTOC subjects were clinical stage IV (33% v 45%, p = 0.01). The MTOC patients had significantly greater odds of bimodal staging (aOR: 2.2 [1.3, 3.8]), trimodal staging (2.6 [1.8, 3.8]), invasive stage confirmation (2.6 [1.7, 3.9]), and mediastinal stage confirmation (2.4 [1.6, 3.6]; all p < 0.01). The additional stage confirmation resulted in more patients who were up- or down-staged in MTOC (44% v 33%, p = 0.03). MTOC patients were twice as likely to receive National Comprehensive Cancer Network guideline-concordant treatment (aOR: 2.0 [1.3, 3.2]). Despite more thorough care, time from initial lesion detection to treatment was similar (mean: 2.86 vs. 2.83 months, p = 0.71). Health-related quality of life measures did not differ between the two arms (P = 0.07 to 0.99). We found no difference in overall (aHR: 1.1 [0.9, 1.4]) or disease free survival (aHR: 1.1 [0.9, 1.3]) between MTOC and TSC. Conclusions: MTOC improved the thoroughness of care and delivery of appropriate treatment, without delays in treatment initiation or survival improvement.

A comparison of two models of multidisciplinary lung cancer care within a community-based healthcare system

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Background: The Multidisciplinary Thoracic Oncology Conference (MTOC) model is easier to implement than the Multidisciplinary Clinic (MDC) model, but does not directly involve patients in decision-making. We compared the processes and outcomes of lung cancer care between patients discussed in a weekly MTOC versus those seen in a MDC. Methods: Prospective observational study of thoroughness of staging, stage confirmation (defined as biopsy of the stage-defining lesion), National Comprehensive Cancer Network guideline-concordant treatment, overall (OS) and event-free (EFS) survival of lung cancer patients in a community healthcare system’s MDC and MTOC from 2014-2019. We used the chi-square test and multivariable logistic regression to evaluate guideline-concordant treatment and stage confirmation; Kaplan-Meier curves and multivariable Cox regression were used to evaluate OS and EFS. We adjusted models for age, sex, race, insurance, smoking status, and histology. Results: 614 patients received care in MDC; 571 in MTOC. MDC patients were older (median age: 69 vs. 67); less likely to be active smokers (44% vs. 47%; p=0.03); more likely to have bimodal (98% v 95%, p=0.02) and trimodal staging (60% v 46%, p<0.0001). The stage-confirmation rate (OR: 1.55; 95% CI: 1.22-1.96) and mediastinal stage confirmation rate (OR: 1.55; 95% CI: 1.23-1.95) were both significantly higher in MDC, even after adjustment (aOR: 1.60; 95% CI: 1.25-2.03); (aOR: 1.58, 95% CI: 1.25-2.00). A higher proportion of patients received guideline-concordant treatment in MDC than in MTOC (82% vs. 73%; OR: 1.63; 95% CI: 1.21-2.20) even after adjustment (aOR: 1.64; 95% CI: 1.20-2.24). However, MTOC patients had significantly better OS (p=0.03) and EFS (p=0.001) than MDC patients and a lower hazard of death (HR: 0.81; 95% CI: 0.67-0.98), even after adjusting for confounding variables (aHR: 0.79 95%CI: 0.66-0.95). Conclusions: Although the processes of lung cancer care delivery were better in MDC than in MTOC, survival was better in MTOC. Patient selection may have played a role in these survival differences. The MTOC model, as implemented, seems competitive with the MDC model and is worthy of further exploration as a more feasible model of multidisciplinary care. [Table: see text]

“When offered to participate”: A systematic review and meta-analysis of patient agreement to participate in cancer clinical trials

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Background: Patient participation in clinical trials (CTs) is vital for knowledge advancement and outcomes improvement. The rate of CT participation for adult cancer patients is between 5%-8%; many CTs fail due to poor accrual. Although patient decision-making is a common focus of studies examining barriers to CT participation, the rate of trial participation for patients actually offered a CT is unknown. Methods: We conducted a systematic review and meta-analysis using PubMed, Web of Science, and Ovid Medline search engines to identify studies over 20 years (1/1/2000-1/1/2020) that examined CT participation. Studies must have been conducted in the United States and specified the number of patients offered a CT and the number enrolled. We conducted a meta-analysis of single proportions using random effects. Rates were examined for both treatment trials and cancer control (CC) studies. We also compared the rates of enrollment between Black, Hispanic, and Asian patients versus White patients. Clinical care setting (academic vs community) was examined as a potential moderator. Results: We screened 3,241 unique citations and identified 35 (30 treatment and 5 CC) studies among which n = 9,759 patients were offered CT participation. Overall, 55.0% (95% CI: 49.4%-60.5%) of patients offered a CT agreed to enroll. Trial participation rates did not differ between treatment (55.0%, 95% CI: 48.9%-60.9%) and CC trials (55.3%, 95% CI: 38.9%-71.1%, p = .98); however, participation rates were significantly higher at academic centers (58.4%, 95% CI: 52.2%-64.5%) versus community centers (45.0%, 95% CI: 34.5%-55.7%, p = .04). In common studies, Black patients agreed to participate at similar rates (58.4%, 95% CI: 46.8%-69.7%) compared to White patients (55.1%, 95% CI: 44.3%-65.6%, p = .88). Results were also similar comparing White versus Hispanic or Asian patients. The main reasons for non-participation were treatment choice or lack of interest. Conclusions: More than half of all cancer patients who are offered CTs do participate; results were consistent between major race/ethnicity groups. This finding upends several conventional beliefs about cancer clinical trial participation, including that Black patients are less likely to agree to participate and that patient decision-making is the primary barrier to participation. Policies and interventions to improve CT participation should focus more on modifiable systemic structural and clinical barriers, such as improving access to existing trials and broadening trial eligibility.

Abstract 4344: Racial representativeness of cancer clinical trials sponsored by the National Cancer Institute compared to pharmaceutical companies

Purpose Many clinical trials supporting new drug applications underrepresent minority patients. Trials conducted by the NCI's clinical trial network (NCTN) have greater outreach to community sites, potentially allowing better representation. We compared the representation of black patients in pharmaceutical company-sponsored cancer clinical trials to NCTN trials and the U.S. cancer population.

Procedures We established a large cohort of study publications representing the results of pharmaceutical-company sponsored trials that supported new U.S. Food and Drug Administration (FDA) drug approvals from 2008-2018. NCTN trial data were from the SWOG Cancer Research Network. U.S. cancer population rates were estimated using Surveillance, Epidemiology, and End Results (SEER) survey data. We compared the proportion of black patients by enrollment year for each cancer type and overall. Comparisons between groups were conducted using tests of proportions.

Results 227 trials (pharmaceutical company-sponsored trials, 74; SWOG trials, 153) comprised of 79,592 patients (pharmaceutical company-sponsored trials, 43,567; SWOG trials, 36,025) for nine specific cancer types were analyzed. Overall, the proportion of black patients was 2.9% for pharmaceutical company-sponsored trials, 8.3% for SWOG trials, and 12.1% for the U.S. cancer population (p&lt;.001 for each pairwise comparison). For each cancer type, the proportion of black patients was statistically significantly lower for pharmaceutical company-sponsored trials compared to SWOG trials (except for melanoma) and compared to the U.S. cancer population.

Conclusions The poor representation of minority groups in pharmaceutical company-sponsored trials is of vital scientific concern. These trials could support the use of new drugs with little data about efficacy or side effects in key populations. Because pharmaceutical company-sponsored trials test the newest available therapies, limited access to these trials represents a disparity in access to potential breakthrough therapies. Pharmaceutical companies could improve racial/ethnic diversity in their trials - and expand access to all patients - through increased outreach to community sites, as suggested by the findings for the NCTN trials. These results have the potential to directly influence policy, as the FDA, in partnership with the American Association for Cancer Research, is currently examining ways to improve representation of black patients in FDA registration trials.

Citation Format: Joseph M. Unger, Dawn L. Hershman, Raymond U. Osarogiagbon, Anirudh Gothwal, Seerat Anand, Arvind Dasari, Michael Overnman, Jonathan M. Loree, Kanwal Raghav. Racial representativeness of cancer clinical trials sponsored by the National Cancer Institute compared to pharmaceutical companies [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 4344.